Successfully Integrating PAP Technology in the Clinic. Loretta Colvin, APRN-BC Nurse Practitioner Clayton Sleep Institute

Transcription

1 Successfully Integrating PAP Technology in the Clinic Loretta Colvin, APRN-BC Nurse Practitioner Clayton Sleep Institute

2 Objectives Review PAP technology options Identify PAP comfort technology Understand variations in technology options available

3 Conflict of Interest I have no conflicts of interest to disclose

4 My Plans Discuss brands common in my practice Focus on newer model features Discuss adherence reports and interpretation later today

5 Cheat Sheet

6 Be Prepared

7 Assess Equipment

8 When to Assess Equipment New set-ups Replacement equipment Yearly follow-up Any complaints Look, listen and feel

9 Machine Look at Equipment Settings: do they match orders? Capabilities: brand, model, AHI & leak Disposables Mask: style, condition Tubing: style, condition Humidifier chamber: setting & condition Filters: condition, large/fine particle Data transfer (modem, card)

10 Listen to Equipment Machine noise Is it REALLY loud? Leak noise Machine, humidifier, tubing Connections and ports Look for holes!

11 Feel the Equipment Check pressure with manometer Verify against pressure setting BEWARE of Auto-ramp Pressure relief (ex: EPR) Bilevel or advanced modality Altitude (manual adjustment) Check heat plate Water level unchanged after use Is humidifier turned on? (zero=off)

12 Altitude Adjustment Auto-adjustment altitude ResMed S8, S9, Airsense 10 (up to 8,000 ft) Respironics System One, M-series pro and auto (up to 10,000 ft) Fisher&Paykel Icon premo & auto, SleepStyle 608 (up to 9,000 ft) Manual adjustment altitude Respironics System One, M-series & Legacy plus 1: ft, 2: , 3: F&P Icon novo and sleep style (other than 608) 1:0-3000, 2: , 3: ?? X?

13 Case Examples Assess Equipment!

14 Pressure Manometer ResMed S9 CPAP Ordered at 10 cm per titration study 4 cm on manometer Auto 4 cm 7 cm on manometer 3 = 3 cm reduction

15 Patient Reported High Pressure New patient, old machine Tried CPAP 4 years ago Felt pressure was too high Manometer reads 30 cm

16 New Machine at Correct Pressure

17 Patient Reported OSA Symptoms Patient moved to Denver from Texas Since move, feels OSA symptoms have returned despite CPAP use Machine set at 9 cm

18 Re-Assessment Re-titration 9 cm optimal (current setting) F/u after study OSA symptoms persist What next? Manometer blowing 6 Has RemStar M-series PLUS machine that does NOT auto-adjust altitude 1 = ft, 3 = ft (Denver 5280)

19 Report Indicates Leak Staff insist patient wearing machine several hours nightly Patient was instructed to bring ALL supplies and machine to clinic CPAP placed on patient Machine REALLY loud

20 Patient Reports Loud Machine Limited hand mobility affects ability to properly close humidifier lid

21 Extra Credit Patient returns for yearly f/u Started CPAP in 2008 history of nightly usage What happened?

22 Answer 2008 recall on certain M- series models-humidifier only Call Respironics customer support with machine serial #

23 Comfort Features Humidification & Pressure Relief

24 Humidification Audience Poll Does heated humidification increase adherence to therapy? Yes No Unsure

25 Humidification Across studies, results are inconsistent for: Adherence, preference, side effects Subgroups w/oronasal symptoms may benefit AASM guidelines (2009) Standard recommendation Am College of Physicians (ACP ) Insufficient evidence, inconsistent findings It is a comfort feature covered by Medicare Commonly ordered at onset of new therapy Sawyer A et al Sleep Medi Review 15: Wickwire E et al, Chest 144(2): Epstein L et al J Clin Sleep Med 5(3): Qaseem, A et al Ann Intern Med 159:

26 Extra Credit Humidification comes standard with PAP therapy order? Yes No Unsure

27 Humidifiers and Orders Humidifier is a separate HCPCS code, technically requires separate order F&P and ResMed AirSense 10 use integrated humidifier, cannot actually be detached. Medicare pays outright for humidifier, even if patient returns machine for non-usage Some insurance may not actually cover humidifier

28 Humidification Fine Tuning Heated Tubing Integrated circuit Beware varied settings for tubing heat vs. humidifier heat, brands vary Note DME must provide tubing ($) Added circuit Insulated tubing cozy

29 Humidification Options Machine System One Respironics S9 ResMed Airsense ResMed Icon Fisher & Paykel Chamber Attachment Chamber Heater Detachable 0-5 regular tubing classic / system one 1-3 heated tubing Preheat option Detachable 0-6 Preheat option Integrated 0-8 Preheat option Integrated 0-7 No preheat option Heated Tubing series Note if heated tubing connected, the 0-5 dial controls tubing, not heat plate controls tubing/chamber Auto controls tubing/chamber Manual separate chamber control Boost L-M-H Note heated tubing must be attached and clicked in to activate heated tubing controls (when patient accessible) Patient Controlled Heated Tubing + If granted access Advanced mode only, push and hold chamber temp to access thermometer icons

30 Special Notes

31 Examples

32 Humidification Discussion Post-menopausal women Teenagers Dry climate Oro-nasal symptoms at baseline Anxious Elderly Long-haul truck drivers

33 Pressure Relief Audience Poll Pressure relief increases adherence to PAP therapy Yes No Unsure

34 Pressure Relief Across studies, findings are inconsistent Benefit, no benefit, mixed results Published studies may not reflect all algorithms Sub-groups with poor adherence may find benefit AASM Guidelines (2009) Consensus recommendation Am College of Physicians (ACP 2013) Low quality evidence (discusses C-flex only) Sawyer A et al Sleep Medi Review 15: Wickwire E et al, Chest 144(2): Epstein L et al J Clin Sleep Med 5(3): Qaseem, A et al Ann Intern Med 159:

35 Pressure Relief (cont) Each manufacturer uses different proprietary algorithm, goes through FDA approval process Designed to selectively reduce pressure Use selectively in patients, not in all patients Know your machines and the varied algorithms. Watch your detailed reports. Consider an add on if issues present later

36 Pressure Relief F&P Sensawake Clinician sets low pressure Senses wake to drop pressure ResMed EPR 1 3 cm pressure Easy-breathe bilevels only Respironics flex Flex 1-3 refers to relative drop Cflex+: 2 cm drop from baseline on exhalation ( mini-bilevel ) Fisher & Paykel Sensawake ResMed EPR Respironics cflex, cflex+ (and aflex, biflex)

37 Special Notes

38 Discussion Pressure relief requires a prescription Yes No Unsure Patients should have uncontrolled access?

39 Discussion (cont) It depends on your DME and your preference: Icon (sensawake) Comes activated out of the box DME must turn OFF (!) SystemOne (flex/flex+) and S9/AirSense 10 (EPR) Clinician must activate at set-up Patient access Always (older machines) Clinician controlled Varies by device

40 Pressure Relief Discussion Lab-initiated feature Do you script for machine by brand? Provider initiation When? Add on feature When? Replacement machines

41 Leak and AHI

42 Leak and AHI Data Reporting Manufacturer Device Leak & AHI Fisher & Paykel Icon Novo - Icon Premo or Auto + ResMed S9 Escape / Airsense 10 CPAP *some detailed data limitations in some software - (auto has AHI) S9 Elite or Auto + Airsense 10 Elite / Auto + Philips Respironics System one REMstar Plus - System one REMstar Pro or Auto + Note The external appearance of the device may be quite similar, but the internal software will vary.

43 Leak

44 Leak Audience Poll A leak > 24 L / min is considered a high leak Yes No Unsure

45 Leak Intentional Leak Total leak (> L/min generally concerning) All the leak reported, including normal leak from mask Intentional (mask) + unintentional (seals) abnormal leak depends on mask and pressure Respironics Black: Large Leak (LL) approx 2X expected leak detected > 1.5 minutes Fisher & Paykel Unintentional Leak Excessive leak (>24 L/min generally high) Leak above what is expected for mask selected on machine Intentional leak only Must have right mask selected for calculation to work Resmed

46 Leak References Each mask manufacturer can provide you with mask leak guides You may find one in your lab

47 AHI

48 AHI Audience Poll An AHI > 10 on a detailed report indicates in-lab titration must be performed Yes No Unsure

49 Extra Credit AHI of zero indicates effective therapy Yes No Unsure

50 AHI and Leak Data AHI and Leak = 0 REMstar System One Plus in Encore Anywhere No AHI detection No leak report statistics

51 Leak and AHI Detection If leak not resolved, AHI detection can be unreliable Use particular caution when monitoring apap AHI (ie no in-lab titration for reference) You will either get both measures, or you will get neither May add noise, detectable by some patients switching machines

52 ResMed Resmed AirView (Easy Care Online) Leak above set threshold for intentional leak (24) AHI not in acceptable range (< 10) Respiratory Events Resmed (ResScan) Excessive Leak Normal Leak

53 F&P Icon Leak and AHI Leak is horrible > 80 L/min (!) AHI wide variation Undetectable AHI is unusual

54 DOT Driver

55 Daily Details DOT Driver

56 DOT Driver

57 AHI Detection - Group Discussion Do you script for AHI detection? When Do you script by manufacturer? When Examples No REM or no supine observed at optimal Monitoring for centrals in certain scenarios Idiopathic centrals on HST with limited in-lab titration option due to insurance or deductible

58 Tips (and a little soapbox)

59 Equipment Assessment Tips Use a manometer Train scheduling staff to advise patient to bring machine and ALL equipment Modem does not always mean data available Have a cheat sheet to help find settings Have power cords for all machines Keep spare cards for all machines in clinic

60 Download Tips Have backup PC based software for all manufacturers Encore Pro, ResScan, InfoSmart Keep version updated, centralize data storage Have a cheat sheet to help break into machines for pressure changes

61 Assessment Tips Double check the DME Check settings vs. orders Check for pressure relief Check the basics (humidifier) Set expectations (ex: AHI detection) Always dig deeper Use detailed reports when there s a problem

62 I m Using My Machine Assess technology Was download done correctly? (ex: wrong dates) Was card inserted in machine? View machine screens to double check Assess patient Clinical improvement? Describe the machine/mask? (ex: color) Would they over-estimate usage? (DOT, insurance) CPAP self-monitoring assessment Log, patient data access (machine, online)

63 ResMed S9 Card holds only 6 mo data

64 A Note on Mouth Breathing OSA patients do not remain mouth breathers. Patient preference for FFM initially Coach patient to consider alternatives to FFM Clinician preference Tech preference during titration DME preference for apap with higher max pressure Alternatives Humidification helpful in many patients Chin strap an option, a good trainer Routine practice with PAP

65 A Note on Claustrophobia Not all claustrophobics are the same Eye crowding, smothering, head straps, small spaces Mask style Some like smaller, away from eyes (pillows) Some want less intense pressure (nasal, FFM) Some want strapless (dental appliance pillow combo) Unique: away from eyes, no pillows (whole face mask) Pressure Air hunger raise ramp or auto-pap min Pressure intolerance reduce pressure for comfort Teach them the ramp (don t assume they know it!) GIVE THEM TIME AT HOME

66 A Note About Oximetry Verify the patient using their PAP when oximetry performed 23:00 pm 2:30 am 3:00 am 6:30 pm

67 Leak Trouble-shooting Look at download (when leak available) Constant Very poor mask fit, defect/hole, removal Turned on but not on patient(!) Fluctuating Patient: mouth opening, positional, removal Equipment: apap pressure changes without proper mask fitting mask change, old seals Examples (next slide)

68 Leak Examples 50 L/min Insomnia leaves machine running when OOB Lost seal after first night Not wearing (DOT)

69 Cost Containment RESmart (3B Medical) Lost cost tubing Durability concerns Low cost machines Download challenges

70 I Want a Smaller Machine Questions to discuss Will there be humidification? Do you require adherence monitoring? Insurance DOT Financial considerations with 2 nd machine e-know-it-looks-strange-why-transcend.html

71 Questions